Perinatal Infratentorial Hemorrhage: A Rare but Possibly Life-Threatening Condition

Background/Purpose: Perinatal infratentorial hemorrhage (PIH) is a rare and clinically difficult to diagnose condition and has been described as a complication of abnormal labor and vacuum extraction.

Case Presentation: After an uneventful pregnancy, a baby boy was born at 41 weeks gestational age. Due to fetal bradycardias birth was facilitated by vacuum extraction (Kiwi). Initial pH was 7.20 and Apgar score 3/6/9. After initial resuscitation, insufficient breathing, reactive pupils, and absence of spontaneous movements were noted. The newborn required intubation and was transferred to the ICU. Diagnosis of neonatal asphyxia with hypoxic-ischemic encephalopathy (HIE) Sarnat stage III was made and therapeutic hypothermia (TH) for 72 hours was initiated. A cerebral ultrasound was conducted, which showed no particularities apart from a mildly hyperechogenic periventricular substance. There were no signs of cardiac, renal or hepatic affection. At physiological body temperature, routine cerebral MRI showed a subdural hemorrhage in the posterior fossa with compression of the 4th ventricle. Signs for HIE had resolved, but periodic breathing and transient bradycardia were still present. Close ultrasonographic and clinical controls were installed to observe for hydrocephalus development, a surgical intervention was not necessary.

Conclusion: Perinatal intracranial hemorrhage occurs in up to 25% of full term neonates, mostly localized in the ventricles. PIH is an atypical location which can be easily missed with ultrasound. It can be life-threatening with compression of the brainstem and development of hydrocephalus requiring surgical intervention. Therefore, in children with birth trauma, PIH may be an important differential diagnosis of HIE.